To the Editor: I found the otherwise laudable
review of guidelines on prevention of a first stroke from the NSA1 lacking in 1 important point. Familial ischemic
stroke is a well-known entity2 and, although
partly explained by familial aggregation of traditional risk factors, clusters
of cases in families who appear free of those risk factors do occur. Such
cases of cryptogenic stroke should be evaluated for several specific etiologies,
including paradoxical embolism and, more importantly, thrombophilia.3 Data suggest that among the many risk factors for
stroke under genetic influence,4 familial
thrombotic coagulopathies can be identified in some cases, in particular activated
protein C resistance due to factor V Leiden mutation5
and possibly primary antiphospholipid antibody syndrome.6
Thus, the NSA recommendations should include the screening of members of families
with unexplained stroke aggregation for possible inherited thrombophilia.
Once recognized, appropriate prophylactic treatment should be considered.